Under Pressure: Increased Intracranial Pressure in Infants and Children. Presented at the 2024 AOC/AACO/AAO Sunday Symposium.

Intracranial hypertension (ICH) in children refers to increased pressure within the skull. The skull normally contains the brain, blood vessels, meninges, and cerebrospinal fluid (CSF). Abnormalities in any of these intracranial structures may cause ICH. The differential diagnosis for pediatric ICH includes brain tumors; intracranial hemorrhages; intracranial infections; craniosynostosis; disorders of CSF production, clearance, or abnormal CSF contents; and pseudotumor cerebri syndrome (PTCS), which may be primary (also known as idiopathic intracranial hypertension [IIH]) or secondary. Children with suspected ICH should undergo a thorough history and examination, focused on determining whether the child has papilledema and/or abducens nerve palsy. The differential diagnosis of papilledema includes other causes of optic disc edema, such as optic neuritis, as well as pseudopapilledema. The differential diagnosis of abducens nerve palsy includes Duane syndrome and other causes of childhood esotropia. In children with suspected papilledema, ancillary ophthalmic testing including visual fields, optical coherence tomography (OCT), fundus photography, autofluorescence, fluorescein angiography, and ultrasonography may be indicated. The systemic workup for children with suspected ICH includes neuroimaging and lumbar puncture in certain cases. Management of children with ICH is focused on treating any underlying cause and lowering intracranial pressure with medications or surgery.